Frequently Asked Questions

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FAQ

What data elements in the MAX data can I use to determine which Medicaid enrollees were also enrolled in Medicare (e.g. which Medicaid enrollees were dual enrollees)?

USING SMRF BEFORE 1996

Person Summary File (before 1996)

The SMRF Person Summary file has the data element, “Eligible Medicare Crossover Code” (data element #11), that identifies individuals who were dual enrollees during one or more months in the calendar year (persons who were “ever” dual enrollees in the year). This data element has four code values to indicate Medicare eligibility status:

• Code value = 0 indicates that the person was never covered by Medicare during the year,

• Code value = 1 indicates that the person was covered by Medicare at some time during the year, based on data in the MSIS Medicaid “Dual-Eligibility-Flag” for this enrollee,

• Code value = 2 indicates that Medicaid paid Medicare copayment and/or deductible amounts on at least one claim during the year for this person, and

• Code value = 3 indicates that both 1 and 2 apply.

Claims Files (before 1996)

The “Eligible Medicare Crossover Code” (claims data element #11), as defined above, is included in each SMRF claims record along with other eligibility data. It should be noted that the dual eligibility status reported in this data element is a measure of persons where were “ever” dually enrolled in the year. This definition may not match the dual eligibility status of the person for the month in which the service was delivered. For example, the person may have been identified as “ever” a dual enrollee based on a Medicaid paid Medicare deductible amount from a claim paid in March. That eligibility status is added to all claims paid in the year. In particular, it is added to a claim paid in January whether or not Medicaid paid Medicare copayment and/or deductible amounts on the January claim.

In General (before 1996)

The defining criteria for dual eligibility depend solely on reporting in Medicaid eligibility and claims payment systems. There have been questions concerning accurate identification of dual eligibles in both of these Medicaid systems. Therefore, there may be some errors in correctly identifying dual enrollees in the MSIS and SMRF data for 1995 and earlier years.

For these years, it is not possible to identify type of dual eligibility (e.g. QMB plus, QMB only, SLMB, etc.) in MSIS and SMRF.

USING SMRF FROM 1996 TO 1998.
Person Summary File (1996-98)

The SMRF Person Summary file has two data elements that identify individuals who were dual enrollees during one or more months in the calendar year (persons who were “ever” dual enrollees in the year).

(1) “Eligible Medicare Crossover Code (old value)” (data element #23) identifies potential dual eligibles in the same way that they were identified for 1995 and earlier years, using code values = 1-3, as defined above, based solely on data from data reported in MSIS. Code values = 4-7 indicate that the Medicaid record for this person was also linked to an eligibility record in the Medicare EDB. These code values = 4-7 are considered to be the most reliable way to identify dual eligibles. This data element has been included in SMRF for data users that want consistency with the definitions that were in use for 1995 and earlier years. Please see the Person Summary File data dictionary for details.

(2) “Eligible Medicare Crossover Code (new value in 1999)” (data element #24) identifies dual eligibles according to the revised instructions to states that apply to MSIS data submissions beginning in FY1999. Therefore, this data element is blank-filled for 1996 and 1997 and it is populated for 1998 based only on the last quarter of Calendar year 1998 (first quarter of FY1999). This data element has been included in the 1998 SMRF data because of the intense interest in dual eligibility by type of dual. The code values for this data element identify the various types of dual eligibles (QMB only, QMB Plus, SLMB only, SLMB Plus, QDWI, QI1, QI2, Other duals and dual/type unknown) according to state reported eligibility codes in MSIS. However, users should note that this data element does not have code values reflecting a link to the Medicare EDB to confirm dual eligibility status. Thus, users may find different counts of dual enrollees using data element #23 versus data element #24.

It should be noted that the quality of coding for “dual-eligibility-flag”, which identifies the various types of dual eligibilities (as noted above) was questionable for many states. This is probably due to the fact that this data element was a new MSIS reporting requirement for Fiscal 1999. In calendar year 1999, the percentage records coded as dual enrollees with dual status unknown was relatively high for many states (e.g. 21 states reported greater than 20% unknown). In addition, five states reported no “full Medicaid benefit” dual enrollees (QMB Plus, SLMB Plus, etc) even though the expectation is that 80-90% of dual enrollees in all states should be identified as “full Medicaid benefit” dual enrollees. Finally, one state (Pennsylvania) did not report on dual enrollee status.

Claims Files (1996-98)

Data on dual enrollment is included with other eligibility data that is added to each SMRF claims record (data elements #12-14). Data element #12 “Eligible Medicare Crossover Code” is taken from the SMRF eligibility data (data element #23 of the SMRF Person Summary File), defined as in (1) above. Data element #13 “Eligible Medicare Crossover Code – Claim-Based” is based solely on the claim in which it occurs. Data Element #14 “Eligible Medicare Crossover Code – New” is taken from SMRF eligibility data (data element #24 of the SMRF Person Summary File), defined as in (2) above.

In General (1996-98)

As a result of the Medicare EDB link, several EDB data elements have been added to the SMRF Person Summary File: eligible Medicare Health Insurance Claim (HIC) number (data element #7), eligible Medicare death date (data element #14), eligible Medicare death day switch (data element #15), eligible Medicare beneficiary months count (data element #25), and eligible Medicare beneficiary – monthly (data element #30).

USING MAX Beginning in 1999

Person Summary File (Beginning in 1999)

The MAX Person Summary file has five data elements: two identify dual enrollees, which are described below:

(A) “Eligible Medicare Crossover Code – Annual, Old Values” (data element #25 for 1999-2004) has code values as defined in (1) above (1996-1998 SMRF files).  This data element does not exist for MAX 2005 and later years.

(B) “Quarterly Eligible Medicare Crossover Code – Old Values” (data element #26 for 1999-2004) has code values as defined in (1) above (1996-1998 SMRF files). Code values indicating a link to the Medicare EDB are omitted. This also matches with the annual definitions used in SMRF for years before 1996.  This data element does not exist for MAX 2005 and later years.

(C) “Eligible Medicare Crossover Code – Annual, New Values” (data element #27 for 1999-2004) has code values as defined in (2) above (1996-1998 SMRF files). In addition, code values = 50-59 and 98 indicate that the Medicaid record for this person was linked to a eligibility record for this person in the Medicare EDB. These code values = 50-59 and 98 are considered to be the most reliable way to identify dual eligibles.   This is renamed “Medicare Dual Code Annually” (data element #35) for MAX 2005 and later years.

(D) “Quarterly Eligible Medicare Crossover Code – New Values” (data element #28 for 1999-2004) has code values as defined in (2) above (1996-98 SMRF files). Code values indicating a link to the Medicare EDB are omitted.  This data element does not exist for MAX 2005 and later years.

(E) “ Medicare Dual Code – Monthly” – This data element exists for MAX 2005 and later years (data element #38).  It was not populated until 2006.

Claims Files (1999-2004)

Data on dual enrollment is included with other eligibility data that is added to each MAX claims record (data elements #12-14). Data element #12 “Eligible Medicare Crossover Code – Annual Old Values” is taken from the SMRF eligibility data in the Person Summary file and is defined as in (A) above. Data element #13 “Eligible Medicare Crossover Code – Claim-Based” is based solely on the claim in which it occurs (if Medicare coinsurance or deductible payments were made by Medicaid). Data Element #14 “Eligible Medicare Crossover Code – Annual New Values” is taken from MSIS and SMRF eligibility data and is defined as in (C) above.

Claims Files (beginning in 2005)

Data on dual enrollment status is included with other eligibility data that is added to each MAX claims record (data elements #19-20).  Data element #19 “Medicare Dual Code – Claim-Based” is based solely on the claim in which it occurs (if Medicare coinsurance or deductible payments were made by Medicaid).  Data element #20 “Medicare Dual Code – Annual” is taken from the MAX Person Summary file.

In General (beginning in 1999)

As a result of the Medicare EDB link, several EDB data elements have been added to the SMRF files: eligible Medicare Health Insurance Claim (HIC) number, Medicare race/ethnicity, eligible Medicare language code, eligible Medicare death date, eligible Medicare death day switch, eligible Medicare beneficiary months count, Medicare original entitlement reason code, Medicare current entitlement reason code and eligible Medicare beneficiary – monthly.

As discussed above, it should be noted that the quality of coding for “dual-eligibility-flag”, which identifies the various types of dual eligibilities (as noted above) was questionable for many states. See the discussion above in the last paragraph of the section “Using SMRF Data from 1996 to 1998, Person Summary File (19996-98)” for additional details. The quality of coding for this data element did improve somewhat for MSIS data submitted for Fiscal 2000 through Fiscal 2002. However, data reporting problems remained. A major effort was undertaken to improve systematic coding problems for this data element in Fiscal 2003 submissions.


(FAQ9720)

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